MEDICARE: DR. CHARLES W. BONNER PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PS-00719-L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	111914000	OTHER	PA	MAGELLAN BEHAVIORALHEALTH
3	111914000	OTHER	PA	AETNA
4	781511	OTHER	PA	HIGHMARK BC/BS

General Provider Information

NPI Number	:	1437145869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES W. BONNER PH.D.

Provider Business Mailing Address
First Line	:	5665 MELVIN ST
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15217-2210
Country	:	US
Telephone Number	:	412-422-9160
Fax Number	:	412-422-8180

Provider Business Practice Location Address
First Line	:	5873 FORBES AVE
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15217-1601
Country	:	US
Telephone Number	:	412-422-9106
Fax Number	:	412-422-8180

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	03/15/2024

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